Melanoma Excision Frequently Delayed in Medicare Population

Jason Lott, MD

One in five Medicare patients with melanoma waits more than 1.5 months after diagnosis to undergo surgery, according to a retrospective study from Yale researchers recently published in JAMA Dermatology.

“Delay for melanoma surgery in this population is more common than we expected,” said Jason Lott, MD, the first author of the study and a postdoctoral fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at Yale School of Medicine, in a press release.

Using the SEER Medicare database, the researchers reviewed data on 32,501 patients diagnosed with melanoma. Typically, surgical removal of melanoma is recommended within 4 to 6 weeks, although no official guidelines exist.

Surgical delay in the study ranged from 4 to 450 days, with a median of 27 days. Of the total study population, 77.7% (n = 25,269) underwent surgical removal within 1.5 months of a biopsy, while 22.3% (n = 7,232) waited to undergo surgical removal for more than 1.5 months. Eight percent (n = 2620) delayed surgery for longer than 3 months.

Surgical delay may result in increased morbidity and mortality for other malignant neoplasms including cancers of the lung, rectum, breast and bladder, but little association has been shown between delay of surgery and survival for melanoma. However, delaying surgery is linked with an increase in anxiety, stress, and psychological harm.

Currently, it is unclear what caused these delays, though the study did discover several possible factors associated with risk.

“We are working to identify reasons for delay in the time it takes for patients to get surgery,” said Lott in the release. “That information will help ensure that we are delivering more prompt and patient-centered surgical care.”

According to the study, 41.9% of patients had melanomas removed by dermatologists, compared with 30.5% removed by general plastic surgeons, 9.1% by Mohs surgeons, and 1.2% by primary care physicians. Delays were most common in patients who were treated by providers who were not dermatologists.

The risk for surgical delay >1.5 months was significantly reduced when a dermatologist performed the biopsy compared with a non-dermatologist (OR, 0.68; 95% CI, 0.57-0.87; P <.001). The risk for delay significantly increased when a primary care physician performed the surgery compared to a dermatologist (OR, 1.49; 95% CI, 1.08-2.08; P =.02), although no significant differences were observed with other specialties.

Compared with a dermatologist performing the biopsy and surgery, there was a significantly higher risk observed for surgical delay when a dermatologist performed the biopsy and a general/plastic surgeon subsequently performed the surgery (OR, 1.49; 95% CI, 1.19-1.87; P <.001).

This particular finding may point to opportunities to increase coordination of care between providers who diagnose and treat melanoma patients, the researchers said.

Age and comorbidity burden were also significantly associated with a delay >1.5 months (P <.001), as was marital status (P = .001).

The risk for surgical delay >1.5 months was significantly associated with being 85 years or older (OR, 1.28; P = .02), prior diagnosis of melanoma (OR, 1.20; P = .001), the presence of 1 to 2 comorbidities (OR, 1.10; P = .002), or 3 or more comorbidities (OR, 1.18; P <.001)

Similar results were found for risk for surgical delay longer than 3 months.

Medicare beneficiaries diagnosed as having primary cutaneous melanoma from January 1, 2000, through December 31, 2009, were included in the study cohort. Patients with one or more case of melanoma were included; however, if two or more cases of melanoma occurred within 1 year, patients were excluded. This is because researchers would be unable to attribute multiple biopsies and surgical procedures to particular melanoma causes during this interval.

Of the 32,501 cases included in the study, 95.4% of patients were white, 63.1% male, 47.9% were married, and 60.8% were 75 years or older. Melanomas were most commonly located on the head or neck (40.5%) and staged as in situ disease (48.2%.) Twenty-five percent of melanomas were classified as stage I, 14.4% were classified as stage I/II, 4% stage II, 5.4% stage III, .07% stage IV, and 1.8% unknown.

Lott JP, Narayan D, Soulos PR, et al. Delay of surgery for melanoma among Medicare beneficiaries [published online April 8, 2015]. JAMA Dermatol. doi: 10.1001/jamadermatol.2015.119.